Forms & Insurance	Back | Next	Ordering/Shipping

Note: We can customize any form, if needed, for an additional charge–name, address, phone, license number, provider number, change of coding and informatoin, etc. Custom order form is contained within the packet. Superbills are not in the Big Forms Packet. They are in this Insurance Forms Packet.

Packet #1 The Health Professional's Big Forms Packet –Patient Based $65.00 Go to What these forms do for your practice Go to Table of Contents below. Why purchase master forms rather than create them from scratch? When ordering, please specify your profession and if you are in a combined professional practice, ie. chiropractic/ acupuncturist, therapeutic massage practice/ osteopathy practice, naturopathy, etc. 150 Mix & Match Forms Includes high quality master forms you may use to photocopy for your own practice use: Some of these forms are patient empowerment forms which are known to increase the practice with their use 195%!

TABLE OF CONTENTS FOR THE BIG FORMS PACKET –PATIENT BASED

New Patient Packet • Patient Rights/ Mutual Understanding in the Therapeutic Relationship • Office Procedure & Patient Introduction • Patient Registration & Authorizations • Welcome Brochure – Policies • Payment of Services Information • New Pt. Information on Insurance • Insurance Questions & Answers for Patients • How to Submit Your Insurance Claim • Verification of Insurance Coverage Patient Histories • Patient History Questionnaire–P.1 • Past Medical History • Patient Profile–p. 2 or • Symptom Review–p.2 • Habits and Preferences p.3 • Nutrition, allergies, Medicines–P.4 • Patient History Questionnaire–P. 1 • Current and Former Conditions– P.2 • Nutrition, Habits, Medicines–P. 3 • Females / Males only • Accidental Injury Questionnaire • Workers’ Comp. Questionnaire • Disability Evaluation Questionnaire • Nutrition Questionnaire–3 Pages • Ayurvedic Nutrition Questionnaire Clinic Charts and Reports • Evidence of Continuity of Care Patient Checklist • Consultation Form • Clinical Charts Long & Short Form • 5 Elements Clinic Chart 2 types • Tongue Diagnosis & Findings • Iridology Findings • Patient Progress Notes • Patient Progress Notes – Modified • Treatment Record Card • Patient Progress Report – Pt. Fill in • Treatment Summary Report • Initial Report • Interim and Final Report • Complete Narrative Report – 4 PP. Consent and Authorization Forms • Consent for Alternative Health Care • Consent for Investigational Devices • Disclosure of Qualifications/ Records • Disclosure of Supervision • Nutrition/Herbs Consultation/Consent • Pre-authorization Form to Treat • Authorization to Release Medical Information • Physician Referral • Authority to Admit Observers • Consent to Photograph • Authorization for Absence • Disability Certificate • Consent to Treat Minor Child • Authorization to Employer for Workers’ Compensation • Treatment and Arbitration Agreement

Patient Care Forms–Continuity of Care (These can be used individually or in the Patient Report of Findings Packet ) • Patient Personal Report p.1 • Schedule of Care, Recommendations p.2 • General Instructions for Care p.3 & 4 • Personalized Instruct. Magnetics p. 1& 2 • Personalized Instructions – P. 3 • Supplement Program – P. 4 • Recommendations • Report of Findings & Health Care Proposal • Patient Wellness Program Contract Referral Building & Patient Follow-Through Material • 7 Appointment and Referral Cards • Thank You for your referral-Letter • Recommendation for pamphlets Appointment Management Forms • Sign-in Register • Professional Appointment Record • Management Control Form #1 • Recall • Reactivation Program Patient / Other Financial Agreements • Payment Plan Schedule • Family Policy • Introducing a Cash Payment System • 60 Days Extension of Credit in Consideration of Assignment • Automobile Accident / Work Injury Policy • Personal Injury Financial Policy • Statement of Report Charges Agreement of Coverage by Patient, Insurance companies, and/ or Attorney • Medical Reports & Practitioner's Lien • Power of Attorney to Endorse Checks to Practitioner's Office Business Contracts • Associate Employment Contract • Colleague Agreement • “No Competition Clause” • Independent Contractor Engagement Agreements (3 @ 3-4 pp. • Partnership Agreement for Acupuncturists Hiring Staff Forms • Interview Questionnaire for Hiring Staff • Job Application Form – 2 pages • Inquiry to Past Employers • Wages Sheet Financial Management Forms • Sample Ledger Card • Sample Accounts Receivable Form • Accts. Receivable Aging & Analysis • Expenses Work sheet – 2 pages • Total Monthly Sum. Income #2 • Income Summary #3 • Take Action Letter • Past Due Collection Letter • Year Sum. of Payments & Fee #4 • Profit and Loss Statement #5

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